Despite the availability of effective pharmaceutical agents, pain is a common and often devastating symptom control problem at end-of-life. We have formulated a model that describes "criteria for adequate pain control" in the outpatient oncology setting. Based on this theoretical model, we have developed a protocol which is testing an opioid titration order sheet structured to provide clear direction for three critical provider behaviors: (1) pain assessment, (2) generation of a treatment plan, and (3) communication of the treatment plan to the patient. The use of a similar order sheet may enhance pain control in the hospice setting; however, the needs and potential barriers to adequate pain control within the hospice setting are unique and largely uninvestigated. Furthermore, the burden imposed by the current clinical protocol on patients and caregivers is excessive for the hospice setting and the primary endpoints are not appropriate to the terminal patient population. Hospice specific factors which may affect pain outcome and/or require alterations in the clinical protocol include: (1) the increasing role of caregivers, (2) the shift to home based care, (3) introduction of hospice staff as part of the health care team, (4) the decreasing role of the primary care team and (5) medical complications of the disease process. Thus, modification of the theoretical model, the opioid titration order sheet, and the protocol, will be necessary in order to test this intervention in the hospice population. Using a mixed methods approach, we propose to identify the unique needs and barriers for pain control in the hospice setting as identified by key stakeholders (patients, caregivers, hospice staff and referring physicians). Based on these data we will modify the theoretical model, the order sheet and the protocol. Once the modifications lave been made, we will conduct a pilot study to assess feasibility, utility and efficacy of the order sheet in the outpatient hospice setting. [unreadable] [unreadable]